Provider Demographics
NPI:1932274461
Name:DALAL, SURINDER P (MD)
Entity type:Individual
Prefix:DR
First Name:SURINDER
Middle Name:P
Last Name:DALAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 PINE ST
Mailing Address - Street 2:SUITE 560
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2173
Mailing Address - Country:US
Mailing Address - Phone:478-745-9998
Mailing Address - Fax:478-745-9981
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:SUITE 560
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-745-9998
Practice Address - Fax:478-745-9981
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-06-05
Deactivation Date:2017-12-21
Deactivation Code:
Reactivation Date:2018-06-05
Provider Licenses
StateLicense IDTaxonomies
GA023934207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00245902AMedicaid
GA00245902JMedicaid
GA00245902JMedicaid